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Scan 515,111 <br /> 4 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)465-3420 <br /> NON-REFUNDABLE PERMIT �i CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR�yFROM DATE ISSUED <br /> JOB ADDRESS r *JLU ` CITY/ZIP � (` CLd [ - " m <br /> m <br /> > <br /> /� <br /> CROSS STREET APN ,?� � 1 PARCELSIZE LAND USE APPLICATION# A <br /> 12 41 <br /> OWNER NAME t� 3,A k PHONE <br /> OWNER ADDRESS ^ 1-t�-�.. �`• x-61, CrY1STATEIZIP CS r-t.1 (r-V1 } <br /> CONTRACTOR ' <br /> �Z c " PHONE �� (� a 7� y q <br /> CONTRACTOR ADDRESS `_ ! ,. !,.) k 13 CITYISTATEIZIP <br /> SUBCONTRACTOR PHONE (� � <br /> SUBCONTRACTOR ADDRESS CITYISTA�TfEtZIP <br /> LICENSE -57 [:1C-61 ❑D-09 ❑Other NUMBER �-7-711) 9 & EXPIRATION DATE 1- Z019 <br /> DOMESTIC WELL SAMPLING:[]General Mineral/Coliform Bacteria (4391)❑DlbrOrnochloropropane (4392)[]Arsenic(4393) <br /> INTENDED USE ,21bomestic/Private ❑IrrlgatlonlAgricultural ❑Industrial ❑Water Quality Monitoring [-]Soil Sampling/Characterization <br /> ❑Rublic Water System <br /> If different from Owner: Water System Name Gontact Name or Phone Number <br /> TYPE OF WORK ❑'New Well /Replacement Well ❑Well Alteration/Modification [-]Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Barings) #of borings ❑Geotechnical #of borings <br /> Ll Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Crass-Connection Repair <br /> El New Pump El Pump Replacement D Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method/Mud Rotary [-]Air Rotary ❑Auger 4Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth 'Jere ft Excavation 1 �` in diameter DO pen Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter ip Thick nesslGaugelASTM Sched_ _g ❑Steel VPlastic L]Stainless Steel ❑Other <br /> Grout Seal Depth } ft -10,Neat Cement(941b bag15-10 gal water) Sand Cement ( sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method ;$Pumped ❑Free Fall ❑Other ❑Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By [-]Driller ump Contractor ❑ Other <br /> ❑Concrete Pedestal dimensions:Width ft length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATI 6A S. <br /> MINIM 4 HOADII C OTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE '�'P6'd}u✓�- DATE 6.Y44 7 <br /> r �= <br /> -f � <br /> s a A <br /> 4N �nof <br /> c <br /> i-DE&�n <br /> TMENT US ONLY <br /> Application Accepted By� Date Area Employee ID# <br /> Grout Inspection 8 Date ❑ ECI L Well Permit <br /> P Y <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Death ft <br /> COMMENTS 1�) <br /> 4&L� r-c—qAtWL L' <br /> PE SC Received hec Amount Date PermlV Invoice# Well ID# <br /> Codes Info B Remitted Service Re uest# <br /> C4 IIS <br /> t*L <br /> EHD 43-06 8101116 WELL IPUMP PERMIT <br />